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Managing skin infections in primary care

Christine Barrett
PhD BSc(Hons) RNT RGN
Senior Lecturer
School of Health Studies
Bradford University and BDNG member

Sara Burr
BN(Hons) RN ENB
N18 DipTropNursing
C&G730
Freelance Dermatology Nurse and BDNG member

Skin and skin-structure infections are common and range from minor pyoderms to severe necrotising infections.(1) This presents a real challenge for primary care nurses, particularly those without easy access to nurse specialists, such as tissue viability and dermatology nurses. It requires diverse knowledge and skills to assess the healthy and diseased skin and produce a nursing diagnosis. A good partnership between the hospital-based dermatology service and the community team may allow a seamless care pathway for patients with skin problems. It may allow the development and update of shared guidelines, standards and policies. For instance, the recent Action on Dermatology project was effective in parts of the UK in supporting some health visitors. Training sessions and specialist community-based dermatology teams and clinics were established.(2)
However, within the realities of community care, it is more likely that the individual nurse autonomously diagnoses skin infection as part of a routine holistic nursing assessment of the patient and suggests or prescribes treatment. The prescribing role has developed considerably since 1992, when the Medicines Act (1968) was amended to enable district nurses, health visitors and some practice nurses to prescribe from a limited formulary.(3) This article is intended to provide support for such nurses. It outlines common skin infections and suggests appropriate nursing interventions.

Defining minor skin infections
No skin infection is minor if it affects the patient's quality of life or has the potential to cause chronic or serious ill-health. Skin infections range from common conditions that are easily treated with over-the-counter (OTC) preparations to major life-threatening infections with a systemically unwell patient.(4) They are diverse in their aetiology and clinical manifestations, and the terminology used for these conditions is often confusing.(1) The easiest division is into primary and secondary conditions. Bacterial infections caused by Staphylococcus aureus and Streptococcus pyogenes will predominate in primary skin infections. The increase in overseas travel and immigration into the UK predisposes to primary fungal infections. Secondary infections are those that complicate an existing chronic skin condition. These are rarely minor, as the underlying disorder (eg, eczema, psoriasis, bullous disorders) allows a portal of entry for more virulent bacteria or the body fails to mount a competent immunological defence.(1) Children suffering from atopic dermatitis are chronic carriers of Staphylococcus aureus, and colonisation usually presents as folliculitis or impetigo.(5)
Nursing vigilance with regard to minor skin infections may prevent the development of severe complications. In individuals with diabetes most foot infections remain superficial, but they can spread to subcutaneous tissues. Infection plays a role in 60% of diabetic foot ulcers that lead to amputation.(6) These facts indicate the importance of careful questioning of the patient and their family members, inspection of the skin and planned nursing intervention, even when the presenting skin condition suggests a relatively minor infection.

Common skin infections or infestations
The skin may be affected by bacterial, viral or fungal infections or infested by insects or helminths. The infective organisms implicated in common skin conditions are listed in Table 1. DiNubile and Lipsky list the bacteria associated with many other possible sources of skin infection that may be of specific interest to  community-based nurses, including salon foot baths, fish tanks and body piercing.(1) Some chronic conditions may exhibit a mixed growth of organisms. Peters  emphasises the importance of distinguishing between bacterial colonisation and infection, as the former will heal without antibiotics.(7) She states that in some conditions (eg, pustular psoriasis) the pus will be sterile. Signs of inflammation and infection may coexist, and in secondary infection of an existing skin condition, such as eczema or psoriasis, the presence of erythema, excoriation and pustules may confuse the diagnosis.

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Identifying minor skin infection
Natural lighting or good artificial lighting is essential for skin inspection, and some patients may have a magnifying glass or lamp in their homes. Halogen lamps used by many of the elderly for needlework or hobbies are perfectly adequate. However, the most useful diagnostic nursing tool is observation of, and comparison with, the patient's healthy skin. This is particularly important in patients of Asian and African origin, as colour changes and rashes may be difficult to determine. Leppard's textbook provides excellent pictures of dermatological disorders in black skin and may be a useful addition to the health clinic's bookshelf.(8) Peters' guide to assessment of the dermatology patient provides a comprehensive overview of skin assessment.(7) Laboratory investigations that may assist in the diagnosis of minor skin infections are bacterial culture and sensitivity determination (impetigo), viral studies (herpes zoster) and mycology investigation for yeast and fungi. The latter may require the collection of skin scrapings, nail clippings and hair debris.

Managing dermal ­infections
The most important aspect of managing infection of the skin is maintaining or restoring the skin as an intact, healthy barrier. Secondly, early nursing assessment and diagnosis are essential. This may prevent a superficial infection of the dermis (erysipelas) spreading to deeper tissues (cellulitis) and leading to hospitalisation. Often, promoting health of the surrounding skin may prevent infection or limit the local spread. This involves maintaining skin integrity through simple hygiene measures and regular use of emollients. In the elderly, secondary skin infections are often the result of persistent pruritis associated with increasing dryness of ageing skin.(9) Thirdly, the implementation of infection control measures is important, particularly if children or poor social conditions are involved. The prevalence of impetigo has reduced, but it remains a condition of the head and neck that distresses children and their families.(4) Fourthly, providing family-centred education is essential to ensure compliance with topical treatments and may lessen reoccurrence. This is a problem with many common skin infections: cellulitis in leg ulcers, folliculitis, athlete's foot, acne. Finally, it is important to address any psychosocial issues related to the stigma that accompanies any highly visible infection.

Potential prescribing issues
Since bacterial infections account for most minor skin infections, short-term topical antibiotics are a common choice of treatment. These may be combined with steroids. The generic principles of prescribing apply, such as ascertaining drug allergies and monitoring for drug sensitisation. Specifically, the prescribing nurse must be aware of the risks of antibiotic resistance, a major challenge in all areas of care and no longer confined to healthcare institutions. The emergence and establishment of methicillin-resistant Staphylococcus aureus (MRSA) over the past decade, followed by vancomycin-resistant enterococcus (VER) and recently vancomycin-resistant Staphylococcus aureus is of great concern.(10) In 19 university-based patients with community-acquired staphylococcal skin infections, 10 (53%) were methicillin-resistant.(11) Patient education on the importance of completing a course of antibiotics and prompt reporting of ineffectiveness of treatment is of paramount importance. The nurse will need to explain the differences between a prescription for antibiotics (eg, bacitracin), antifungals (eg, griseofulvin) and antivirals (eg, aciclovir), as these may not be obvious to the patient. Patients may view topical treatments as potentially less beneficial than oral medications. However, superficial fungal infections of the feet that are common in the elderly are treated effectively by topical antifungal agents.(12) They are also less expensive than oral agents.
Within a prescribing role, an understanding of the costs of the antibiotics that are effective against MRSA is essential nursing knowledge, as is caution with novel products. Treatment of invasive fungal infections is increasingly complex, and, although newer agents cause less nephrotoxicity than amphotericin B, side-effects can still occur.(13) Other issues are that patients will use OTC medications as well as those prescribed. The popularity of tea tree oil may be boosted by recent evidence of its efficacy in reducing scabies mites.(14) Indeed, there may be insufficient evidence base for some medically prescribed regimens. Intertrigo - inflammation of the top layers of the skin, especially in skin folds, caused by moisture, bacteria or fungi - is common in the elderly. An analysis of the large variety of topical antifungals and disinfectants administered in 24 studies provided no scientific evidence for the prescribed treatment strategy.(15)

Conclusion
In some primary care groups, novel methods have evolved to support dermatology service delivery such as triaging GP referrals and specialist nurses.(16) But many primary care nurses remain individually responsible for assessing and diagnosing skin infections. These are often irritating, common or "minor" conditions, for which the patient may purchase OTC medications or use complementary therapies before seeking professional advice. But they do have the potential to be lethal or cause the patient severe harm. Nurses working in the community have an important role in this field and are increasing their knowledge of these skin problems and the associated prescribing issues to ensure evidence-based nursing practice.

References

  1. DiNubile MJ, Lipsky BA, Complicated infections of the skin and skin structures: when the infection is more than skin deep. J Antimicrob Chemother 2004;53 Suppl 2: II37-50.
  2. Neild N. Supporting health visitors to set up an eczema clinic in primary care for pre-school children. Dermatol Nurs 2003;2(4):8-10.
  3. Jackson K. Update on nurse prescribing. Dermatol Nurs 2002;1(3):11.
  4. Docherty C. Infections and ­infestations. In: Hughes E, Van Olselen J, editors. Dermatology nursing:a practical guide. London: Churchill Livingstone Harcourt Publishers Ltd; 2001. p. 205-20.
  5. Hoeger PH, et al. Staphylococcal septicaemia in children with atopic dermatitis. Pediatr Dermatol 2000;17:111-4.
  6. Lipsky BA. A report from the ­international consensus on diagnosing and treating the infected diabetic foot. Diabetes Metab Res Rev 2004;20 Suppl 1:S68-77.
  7. Peters J. Assessment of the ­dermatology patient. In: Hughes E, Van Olselen J, editors. Dermatology nursing: a practical guide. London: Churchill Livingstone Harcourt Publishers; 2001. p. 19-40.
  8. Leppard B. An atlas of African dermatology. Oxford: Radcliffe Medical Press; 2002.
  9. Laube S, Farrell AM. Bacterial skin infections in the elderly: diagnosis and treatment. Drugs Aging 2002;19:331-42.
  10. Jarvis WR . Controlling ­antimicrobial resistant pathogens [editorial]. Infect Control Hosp Epidemiol 2004;25:369-72.
  11. Cohen PR, Kurzrock R. Community-acquired methicillin-resistant Staphylococcus aureus skin infection:an emerging clinical problem.J Am Acad Dermatol 2004;50:277-80.
  12. Tan JS, Warren S. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging 2004;21:101-12.
  13. Slavin MA, et al. Guidelines for the use of antifungal agents in the ­treatment of invasive Candida and mould infections. Intern Med J 2004;34:192-200.
  14. Walton SF, et al. Acaricidal activity of Melaleuca alternifolia (tea tree) oil: in vitro sensitivity of sarcoptes scabiei var hominis to Terpinen-4-ol. Arch Dermatol 2004;140:563-6.
  15. Mistiaen P, et al. Preventing and treating intertrigo in the large skin folds of adults: a literature overview. Dermatol Nurs 2004;16:43-6, 49-57.
  16. Wong Y, Ratnavel R. Key ­developments in dermatology. Practitioner 2001;245:898-910.

Resources
British Dermatology Nursing Group
W:www.bdng.org.uk